GAUTAM BUDDH TECHNICAL UNIVERSITY, LUCKNOW

(Formerly UTTAR PRADESH TECHNICAL UNIVERSITY)

APPLICATION FORM FOR ADMISSION TO Ph.D. PROGRAMME
For Office Use Only

Application No. .. / 2011-I

Field/Area of Research : ..
Decision of RDC

RDC Meeting Ref No. ..

Date : .. Action :

ACCEPT/

REJECT
REGISTRATION NO . :

APPLICATION FEE DETAILS

Demand Draft No. ..

Date of Issue : .

Amount : Rs.

Branch : .

Issuing Bank :...

(The Demand Draft should be in favour of The Finance Officer, Gautam Buddh Technical University, Lucknow
payable at Lucknow.)

Note : The form has four parts : A, B, C, and D. Please read the complete form carefully before filling and attach all
the documents as suggested in the checklist.

PART A : DETAILS ABOUT APPLICANT

1. Name of the Applicant
(in Hindi)

..

(in English) ..
2. Fathers Name : ..

Photograph of
applicant with
signature across
photo

3. Mothers Name :..

4. Permanent Address :.
PIN :....
Ph. No. with STD Code :... Mobile No. ... email .
5. Address for Correspondence : .
PIN : ...
Ph. No. with STD Code :... Mobile No. ... email .
6. Date of Birth : (dd/mm/year) .. 7. Gender : (Male/Female) .
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Gautam Buddh Technical University, Lucknow

Ph D Application Form

Page 1

8. Category : (GEN/OBC/SC/ST/PH) 9. Nationality : .....

10. University Enrolment No. : ( if already enrolled with University) ....
11. Details of National Level Examination Qualified : (if any)
GATE/CSIR/NET/UGC (if applicable) : Score/AIR....

Discipline.. Year

12. Educational Qualifications :

Examination
Passed
High School

Group/
Branch of Engg.

Board/College/University

Year

% Marks
/CGPA

Division

Intermediate
Bachelors
Masters
Any other

13. Details of Employment : (if applicable) in chronological order

Organization

From

To

Designation

Nature of
Responsibilities

14. Details of Research Publications : (if any)

Author(s)

Title of the Paper

Journal/Conference

Volume, No. Page(s)

Year

15. Source of Financial Assistance: (if any) .

*P.S. : Please note that Gate score is valid for two years only.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Gautam Buddh Technical University, Lucknow

Ph D Application Form

Page 2

PART B - DETAILS ABOUT PROPOSED RESEARCH AND SUPERVISOR(S)

16. Field/Area of Research.: .
17. Proposed Research Topic : .
..
18. Name(s) of Supervisor(s) :
Qualifications :
Designation : ..
Address for Correspondence : .
PIN :...
Ph. No. with STD Code :... Mobile No. ... email .
19. Synopsis of the Proposed Research Work

(in not more than 500 words) : Attach a

separate sheet.

20. Referees : List the names and addresses (including mail ID & mobile) of two persons (other
than proposed supervisors) who have taught you or supervised your research work (if
any). Obtain the letters (two) of reference in a sealed envelope and enclose with application.
1. ....

2. .

...

...

...

DECLARATION
I declare that the details furnished in the application and enclosures are correct and I
have gone through the Ph.D. ordinances of the University and promise to abide by them.
In case any entry in this form or in the enclosures is found to be false, I will have no
objection if the University disqualifies me or cancels my candidature at a later stage after
registration.

Place :

Full Signature of Applicant :

Date :

Name : ..

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Gautam Buddh Technical University, Lucknow

Ph D Application Form

Page 3

PART C - DETAILS ABOUT PROPOSED SUPERVISOR

(To be filled by the Supervisor)
(a)

Name : ...

(b)

Present Designation : ...

(c)

Institution/University/Organization where working : ...

(d)

Address for Correspondence : ...

PIN :...
Ph. No. with STD Code :... Mobile No. ... email .

(e)

Qualifications :
(Please enclosed a brief bio-data)

(f)

Fields of Specialization : ..

(g)

Total Experience (yrs.):

(i) Teaching: ........

(ii) Research : ..

(h)

Publications : Refereed Journals

(i) International: .

(ii) National : ..

Conference Proceedings (i) International: .

(i)

Total Number of Supervision :

(j)

No. of research candidates already enrolled in

Ph. D. : .

(i) G B Technical University :

(k)

(ii) National :.
Masters : ...

(ii) Other University :

Are you already an Approved Ph D Thesis Supervisor of G B Technical University?

(If not, kindly enclose a copy of your brief curriculum vitae)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Gautam Buddh Technical University, Lucknow

Ph D Application Form

Page 4

PART D CERTIFICATES AND ACCEPTANCES

(The Applicant is required to approach the concerned individuals and
authorities to obtain the certificates and necessary permissions)
CERTIFICATE AND ACCEPTANCE BY THE SUPERVISOR
(Use copy of this format in case of more than one Supervisor)
This is to certify that the details given in the Application Form are true to the best of my
knowledge and belief. I agree to supervise Mr./Ms.for persuing
the research work at the Gautam Buddh Technical University, Lucknow in the field and on
the topic proposed .

Date :

Signature of Supervisor : ....

Name :.

CERTIFICATE FROM THE HEAD OF ORGANIZATION OF THE SUPERVISOR

(Use copy of this format in case of more than one Supervisor)
This is to certify that Dr . is working as a
.................. in this organization from the year . . He/She
fulfills the necessary requirements for supervising Ph D research work at the Gautam
Buddh Technical University, Lucknow in the field and on the topic proposed .

Date :

....

Seal :

Signature of Head of the Organization

Name :.

CERTIFICATE FROM HEAD OF ORGANIZATION OF THE RESEARCH PLACE

This is to permit Mr./Ms. for persuing the research work in
our organization. The organization will provide the necessary facilities for pursuing the
research work.

Date :
Seal :

....
Signature of Head of Research Place
Name :.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Gautam Buddh Technical University, Lucknow

Ph D Application Form

Page 5

CONFIDENTIAL

PART E LETTERS OF REFERENCECE (2 Nos.)

GAUTAM BUDDH TECHNICAL UNIVERSITY

(Formerly Uttar Pradesh Technical University)
LETTER OF REFERENCE FOR ADMISSION TO Ph. D. PROGRAMME
To be filled in by the Applicant

Name of Applicant : .
Field of Research : .
1. Name of Referee : ...
2. Designation /Position : ...
3. Address : .......
Phone : .. Mobile No. : email : ..
4. Professional Qualifications : ....
5. I

have

known

(academically

only)

the

applicant

for

years

as

his/her

(capacity)

..
6. My rating of the candidate is as follows (please put a tick mark) :
Attributes

Excellent

Good

Poor

Unable to judge

Analytical Ability
Experimental Skills
Motivation
Written and Oral Expression
Responsibility
Teaching Ability

7. Any other comments

8.

(strength/weakness)

..

Recommend without any reservations

Recommend

Do not recommend

Signature :
Kindly handover the reference letter to the applicant in a sealed envelope.
We greatly appreciate for your time in helping the University.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Gautam Buddh Technical University, Lucknow

Ph D Application Form

Page 6

PART F - CHECKLIST
(Tick the Enclosed Documents. Please enclose only attested COPIES. Do not send
ORIGINALS.)
Sl No

Tick

1*

Particulars

Demand Draft of Rs 1000=00 in favour of The Finance Officer,

Gautam Buddh Technical University, Lucknow payable at Lucknow.
Date of Birth Certificate or the High Scool (class X) Certificate with
Date of Birth.
SC/ST/OBC/PH certificate (if applicable).

4*

Copies of degrees, marks/grade sheets of all the examinations passed.

No Objection Certificate from the employer (for employed applicants).

Certificate of Financial Assistance (if applicable).

Copies of publications (if applicable).

8*
9*

Synopsis of proposed research work ( maximum 500 words on one A4

sheet)
Certificates (3 Nos. as per details in Part D)

10*

Copy of detailed Curriculum Vitae of the Supervisor(s).

11*

Two letters of reference in closed envelopes..

2*

Total

No. of Enclosures :

No. of Sheets :

* : Required
Signature :

Indicative List of Broad Areas of Research

GBTU Research Vision 2011.1 : The University encourages the interdisciplinary research in the areas of
energy, environment and health sciences and technologies.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Gautam Buddh Technical University, Lucknow

Ph D Application Form

Page 7